WHO GETS HOSPICE VISITS AT THE END OF LIFE: A LOOK AT MEDICARE'S HOSPICE SERVICE INTENSITY ADD-ON POLICY

Abstract In 2016, the Centers for Medicare & Medicaid Services (CMS) implemented the Service Intensity Add-on (SIA) payment for the Medicare Hospice Benefit. The SIA incentivizes direct patient care by registered nurses and medical social workers during the last seven days of life through additional payments to hospices. We examined 100% of Fee-for-Service Medicare hospice claims in Fiscal Year 2020 to determine whether SIA utilization varies by patient and hospice characteristics. Using hospice level fixed-effects regression, we examine the associations between SIA utilization and various beneficiary and hospice characteristics. Relative to beneficiaries with cancer as a principal diagnosis, we find that other diagnoses are associated with only a slight reduction in SIA utilization (a reduction between 0.6 and 1.1 percentage points - where the average SIA utilization overall is equal to 85.3%). Those identifying as black had a reduction in SIA of 1.3 percentage points compared to those identifying as white. Compared to a patient dying on a Sunday, a patient’s death on Tuesday through Friday was associated with a higher likelihood of SIA (between 9.7 and 11.6 percentage points more likely) and more SIA minutes (between 29.9 minutes and 36 minutes). All reported results were statistically significant at the 0.1% level. Based on these results, we find that SIA utilization varied by certain characteristics. As a result, CMS should continue to monitor rates of SIA utilization to better understand whether any patient groups appear to be underserved at the end of life.

Hospice and palliative care (HAPC) research has shown participation in research benefits both patients and caregivers. However, recruiting participants for HAPC research can be difficult and requires flexible, adaptive, and creative strategies. This presentation will review ongoing efforts for recruitment and subsequent alterations for an active NIH study of patients and their caregivers who have been discharged alive from hospice. A live discharge occurs when a hospice patient medically stabilizes, no longer meeting policy's prognosis eligibility criteria. In 2019, hospices in the United States served more than 1.6 million people, and 17.4% were discharged alive from hospice care, with 6.5% due to being 'no longer terminally ill' (NHPCO, 2021). Currently, there is not an explicit discharge process available to guide practitioners in transitioning patients and caregivers out of hospice care, creating challenges and opportunities for collaborative research.Despite existing relationships with hospice networks, our initial recruitment strategy of recruiting patients and caregivers through direct referrals has been insufficient. Incorporating creative solutions to boost recruitment efforts appears to be effective. First, we developed partnerships with hospital/health systems for identification of eligible partnerships using existing information available in Electronic Medical Records (EMRs), yielding an initial 80% increase in referrals. Additional recruitment efforts include using brief informational videos on social media platforms, such as YouTube, Twitter, and TikTok. Promising recruitment strategies for hard-to-reach populations such as HAPC patients and their caregivers, including identification and outreach using existing EMRs, expanding eligibility to include retrospective data, and integrating efforts across social media platforms.

WHO GETS HOSPICE VISITS AT THE END OF LIFE: A LOOK AT MEDICARE'S HOSPICE SERVICE INTENSITY ADD-ON POLICY
Michael Plotzke 1 , and Thomas Christian 2 , 1. Abt Associates,Saint Louis,Missouri,United States,2. Abt Associates,Cambridge,Massachusetts,United States In 2016, the Centers for Medicare & Medicaid Services (CMS) implemented the Service Intensity Add-on (SIA) payment for the Medicare Hospice Benefit. The SIA incentivizes direct patient care by registered nurses and medical social workers during the last seven days of life through additional payments to hospices. We examined 100% of Fee-for-Service Medicare hospice claims in Fiscal Year 2020 to determine whether SIA utilization varies by patient and hospice characteristics. Using hospice level fixed-effects regression, we examine the associations between SIA utilization and various beneficiary and hospice characteristics. Relative to beneficiaries with cancer as a principal diagnosis, we find that other diagnoses are associated with only a slight reduction in SIA utilization (a reduction between 0.6 and 1.1 percentage points -where the average SIA utilization overall is equal to 85.3%). Those identifying as black had a reduction in SIA of 1.3 percentage points compared to those identifying as white. Compared to a patient dying on a Sunday, a patient's death on Tuesday through Friday was associated with a higher likelihood of SIA (between 9.7 and 11.6 percentage points more likely) and more SIA minutes (between 29.9 minutes and 36 minutes). All reported results were statistically significant at the 0.1% level. Based on these results, we find that SIA utilization varied by certain characteristics. As a result, CMS should continue to monitor rates of SIA utilization to better understand whether any patient groups appear to be underserved at the end of life.

LIVE DISCHARGE FROM HOSPICE WITH DEMENTIA: CHALLENGES TO SUPPORTING THE PATIENT-CAREGIVER DYAD
Stephanie P. Wladkowski 1 , Cara L. Wallace 2 , and Karla Washington 3 , 1. Bowling Green State University,Bowling Green,Ohio,United States,2. Saint Louis University,Saint Louis,Missouri,United States,3. Washington University in St. Louis,St. Louis,Missouri,United States A live discharge from hospice disrupts care continuity and results in burdensome transitions for individuals with a lifelimiting illness and their caregivers. In 2019, hospices served more than 1.6 million people across the United States, with nearly 63% of Medicare decedents age 85 or older. Of these patients, nearly 350,000 (20.9%) had a principal diagnosis of Alzheimer's Disease/Dementia/Parkinson's Disease. Research demonstrates that hospice care improves end-of-life outcomes for adults with Alzheimer's Disease and related dementias (ADRD), yet with eligibility limited to a six-month prognosis, hospice is not structured to meet longer-term needs. The result is a live discharge from hospice. In 2019, 17.4% of hospice patients were discharged alive from hospice, with 6.5% discharged due to being 'no longer terminally ill.' The majority of live discharges are either hospice-initiated due to patient stabilization (extended prognosis resulting in a situation in which a patient no longer meets the life expectancy hospice eligibility criteria) or are patient-initiated (revocation) where a patient or proxy chooses to leave hospice care, typically to access disease-directed therapies or inpatient hospitalization. Both present unique challenges and opportunities for hospice providers. Informed by over 10 years of practice experience and research, this presentation will discuss the impact of live discharge from hospice and the unique impact for patients and primary caregivers of individuals with ADRD, the service gaps that exist for this population, and our recommendations for policy reform.

BUILDING A PROTOCOL FOR LIVE DISCHARGE FROM HOSPICE: UNDERSTANDING THE APPROACHES, CHALLENGES, AND OPPORTUNITIES
Stephanie P. Wladkowski 1 , Tracy Schroepfer 2 , and Susan Enguidanos 3 , 1. Bowling Green State University, Bowling Green, Ohio, United States, 2. University of Madison,Wisconsin,United States,3.

University of Southern California, Los Angeles, California, United States
A live discharge from hospice can occur when a patient stabilized under hospice care no longer meets the life expectancy hospice eligibility criteria. In 2019, 278,400 hospice patients across the United States were discharged alive from hospice care, with 18,096 (6.5%) discharged due to being 'no longer terminally ill.' For these individuals and their caregivers, the result is a disruption of care continuity and an often burdensome transition. Hospice care improves end-of-life outcomes for some patients, and a live discharge results in lost access to important supportive services and resources, while the patient remains 'terminal.' Further, an increased burden is placed on primary caregivers who may be unprepared for this transition. Currently, there is no explicit discharge process available within hospice to guide practitioners in transitioning patients and their caregivers out of hospice care. This study aimed to garner a deeper understanding of current approaches and accompanying challenges to inform the development of an explicit live discharge protocol. Focus group interviews with hospice social workers at four hospice agencies across the U.S. were conducted. Using thematic analysis, four key themes emerged, including the logistical (n=13) and psychosocial (n=9) approaches, the need for clear professional roles during a live discharge (n=12), and specific challenges (n=14), such as needed services and desired discharge timeline to best support the patient-caregiver dyad. Findings demonstrate the complexities of conducting a live discharge, the uniqueness of each hospice agency, and the need for more research to support a standardized and reimbursable discharge process.

THE RELATIONSHIP BETWEEN PHYSICIAN VISITS AND ADVANCE CARE PLANNING
YuHsuan (Olivia) Wang 1 , and Susan Enguidanos 2 , 1. USC,Los Angeles,California,United States,2. University of Southern California,Los Angeles,California,United States Some studies have shown that advance care planning (ACP), discussions about future care given a serious illness, are associated with improved quality of death and better end-of-life care. Studies also have found that physicians play an important role in ACP. In fact, in 2016 CMS began reimbursing physicians for ACP discussions. However, little is known about the relationship between the number of physician visits and engaging in ACP . This study investigated the association between outpatient physician visits and ACP engagement. Only respondents over 65 were included in our study. We conducted logistic regressions using the 2016 Health and Retirement Study. We used ACP engagement (n=9838), advance directive (AD; eg, living will) completion (n=9746), and healthcare power of attorney (e.g., proxy) assignment (n=9724) as outcome variables. In addition to the frequency of physician visits, we controlled for basic demographics (age, gender, marital status, race, and socioeconomic status), number of chronic conditions, and self-rated health in our models. For each additional physician visit, the probability of having an ACP conversation, (p<.001), AD completion (p<.001), and healthcare proxy assignment (p<.001) increased by 1.6%,1.4%, and 1.9% respectively after controlling for covariates. Number of chronic conditions also was independently and positively associated with ACPrelated activities. Additionally, greater perceived health was associated with higher odds of AD completion (OR= 1.08, p<.05) and healthcare proxy assignment (OR= 1.07, p<.05). This study found that frequent encounters with physicians are associated with higher rates of ACP engagement even after controlling for health conditions.

DO DIFFERENT ADVANCE DIRECTIVES CREATE CONFUSION ON A PATIENT'S WISHES? (MOLST VERSUS FIVE WISHES)
Taylor Perre 1 , and Yuchi Young 2 , 1. Home Care Association of New York State, Albany, New York, United States, 2.